PRACTICE STANDarD Restraints Table of Contents Introduction 3 What are Restraints? 3 Assumptions 4 Policy Direction: Least Restraint 4 Quality Practice Settings 5 Nursing Responsibilities 5 Case Studies 6 Resources 9 OUR Mission is to protect the public’s right to quality nursing services by providing leadership to the nursing profession in self-regulation. OUR Vision is excellence in nursing practice everywhere in Ontario. Restraints Pub. No. 41043 ISBN 1-894557-46-8 Copyright © College of Nurses of Ontario, 2009. Commercial or for-profit redistribution of this document in part or in whole is prohibited except with the written consent of CNO. This document may be reproduced in part or in whole for personal or educational use without permission, provided that: • Due diligence is exercised in ensuring the accuracy of the materials reproduced; • CNO is identified as the source; and • The reproduction is not represented as an official version of the materials reproduced, nor as having been made in affiliation with, or with the endorsement of, CNO. First published March 2000 as A Guide on the Use of Restraints (ISBN 0-921127-71-5) Reprinted October 2000, Revised for Web June 2003, January 2004, Reprinted December 2005, May 2008. Updated June 2009. Additional copies of this booklet may be obtained by contacting CNO’s Customer Service Centre at 416 928-0900 or toll-free in Ontario at 1 800 387-5526. College of Nurses of Ontario 101 Davenport Rd. Toronto, ON M5R 3P1 www.cno.org Ce fascicule existe en français sous le titre : La contention, no 51043 3 Practice StaNDarD Nursing standards are expectations that contribute and addresses the principle of minimal restraint on to public protection. They inform nurses of their clients. The Act is consistent with this document, accountabilities and the public of what to expect of the College of Nurses of Ontario’s (CNO’s) nurses. Standards apply to all nurses regardless of their Restraints practice standard. It includes components role, job description or area of practice. such as staff training, reassessment, record keeping, — College of Nurses of Ontario client consent, policy development relating to restraint use and alternative methods. Introduction The purpose of this document is to help nurses¹ Many facilities in Ontario use a least restraint understand their responsibilities and make philosophy. This philosophy acknowledges that the decisions regarding the use of restraints. Restraints, quality of life for each client, with the preservation whether physical, environmental or chemical, are a of dignity, is the value guiding the practice of health controversial measure used to restrict the movement care practitioners, including nurses.² CNO supports or control the behaviour of a client. this in all settings where nurses practise. Reasons for using restraints include protecting Nurses believe strongly in the right of clients to clients from injury, maintaining treatment and make their own decisions regarding care. When controlling disruptive behaviour. According to the client is not competent, the substitute decision- Prevention of Falls and Fall Injuries in the Older maker is expected to make the same decision the Adult (2002, Nursing Best Practice Guideline, client would have made if he/she were competent. Registered Nurses Association of Ontario), several Nurses, as client advocates, are responsible for studies have found that restraints actually increase ensuring that the client has received information the severity of falls and can increase confusion, and has been a partner in planning and consenting muscle atrophy, chronic constipation, incontinence, to the proposed plan of care. Nurses respect client loss of bone mass and decubitus ulcers. Restraint wishes even when those wishes carry risk. use is also linked to emotional distress, including loss of dignity and independence, dehumanization, Increasing numbers of facilities are reporting success increased agitation and depression. In severe cases, in achieving the goal of restraint-free care. Changes clients have been seriously injured or have died in institutional policies have led to the development after becoming trapped in a restraint, such as a of educational programs and assessment tools bed rail. Coroners’ inquests in North America have that assist care providers in finding alternatives cited the use of restraints as the cause of numerous to restraints. The programs have offered nurses deaths due to strangulation. There are no studies a process for identifying precipitating behaviour that demonstrate that the use of restraints results in and have encouraged implementation of policies of increased client safety. least restraint.³ Quality practice settings effectively support nurses in achieving the goal of restraint When and how restraints are used is also a legal reduction. The use of restraints is an intervention of issue. In 2001, the Ontario government passed Bill last resort and is based on meeting the needs of the 85, the Patient Restraints Minimization Act. The client. Act regulates when and how restraints may be used 1 In this document, nurse refers to a Registered Practical Nurse (RPN), Registered Nurse (RN) and Nurse Practitioner (NP). 2 Ontario Hospital Association. Position Paper on the Use of Restraints. Toronto: Author, 1993. 3 England, W., Godkin, D., & Onyskiw, J. Outcomes of Physical Restraint Reduction Programs for Elderly Residents in Long Term Care — A Systematic Overview. Alberta Professional Council of Licensed Practical Nurses, 1997. College of Nurses of Ontario Practice Standard: Restraints 4 Practice StaNDarD What are Restraints? including information about least restraint Restraints are physical, chemical or environmental practices and the right to refuse proposed measures used to control the physical or behavioural interventions. activity of a person or a portion of his/her body. Physical restraints limit a client’s movement. 4. Consent is essential to nursing interventions. Physical restraints include a table fixed to a chair Clients have the right to make decisions regarding or a bed rail that cannot be opened by the client. their care and treatment. The nurse informs the Environmental restraints control a client’s mobility. client or substitute decision-maker of any proposed Examples include a secure unit or garden, seclusion intervention and alternative measures available. or a time-out room. Chemical restraints are any Nurses cannot use any form of restraint without form of psychoactive medication used not to treat client consent, except in an emergency situation illness, but to intentionally inhibit a particular in which there is a serious threat of harm to the behaviour or movement. individual or others, and all other measures have been unsuccessful. Emergency situations are time- What is considered a restraint may vary by limited. Once the situation is no longer critical, practice setting. For example, a nurse working in a client consent is required. (For more information on correctional facility cares for an entire population these issues, see CNO’s Ethics practice standard and of clients who are restrained by the environment. Consent practice guideline.) In a paediatric setting, nurses typically do not view the use of cribs as a form of restraint. CNO 5. Restraint reduction is an interprofessional acknowledges that nurses are in the best position process. Nurses collaborate with other members to determine appropriate definitions of restraint for of the health care team, including the client or their specific practice settings. substitute decision-maker, in assessing, planning and evaluating client care to eliminate restraint Assumptions use. Nurses share knowledge about the risks of Professional judgment is integral to decision- restraint use with the interprofessional team. making and includes organizing data, giving it meaning and coming to a conclusion. Policy Direction: Least Restraint Least restraint means all possible alter native 1. Nursing interventions promote well-being and interventions are exhausted before deciding to use prevent harm. Nurses respect the dignity of the a restraint. This requires assessment and analysis individual and advocate for an environment that of what is causing the behaviour. Most behaviour promotes a client’s quality of life. has meaning. When the reason for the behaviour is identified, interventions can be planned to 2. A least restraint policy does not mean that resolve whatever difficulty the client is having that nurses are required to accept abuse. contributes to the consideration of restraint use. For example, if a client has poor balance or is frequently 3. Nurses involve clients or substitute decision- falling, an intervention, such as providing the makers in planning. It is important for client a walker, can be developed to help protect the nurse to develop a plan of care with the the client’s safety while allowing freedom of client and the client’s family. The health care mobility. A policy of least restraint indicates that team, which includes the client, discusses the other interventions have been considered and/ proposed interventions to identify the client’s or implemented to address the behaviour that is therapeutic needs and to facilitate the client’s interfering with client safety. short-term and long-term goals. To assist decision-making, nurses provide education CNO endorses the least restraint approach. Nurses for clients or their substitute decision-makers, need to assess and implement alternative measures College of Nurses of